Policy and Practice in the Care of Older People

Introduction to Dementia 

According to the World Health Organization (2019), dementia is one of the major causes of dependency and disabilities in older people. Around 50 million people in the world suffer from dementia every year and the most common sufferers of dementia are the older people. The people who are above the age of 65 years are at high risk of dementia. The patients of dementia require more support and care than the other patients as they have poor memory and they face difficulty in performing their daily activities. According to a media report in 2019, several healthcare professionals in Australia are using overuse of dementia medicines and chemical restraints to control the behaviour of dementia people. This is against the ethical standards of nursing as no healthcare expert has the right to use any medication or treatment method that causes harm to the patient. According to certain media articles such as "Australia: Older People in Aged Care Drugged Up (2019)", several aged care homes are using banned medicines such as antipsychotics to treat the uncontrollable behaviour of dementia patients (Human Rights Watch, 2019). This is unacceptable behaviour as it breaches both the legal and ethical standards of nursing. This paper aims to critically evaluate the policies that can help in providing better care to dementia patients. This paper also includes certain recommendations and new policies that can prevent the unethical use of medication administration to control the behaviour of dementia patients. It also has a detailed action plan to successfully implement these recommendations and policies.

Overview of The Current Policy

As per Lim and Sharmeen (2016), dementia is a type of progressive chronic disorder that leads to cognitive impairment and affects the brain and neurological system of the body. There is no proper treatment for this disorder but the symptoms can be treated by the use of medications. The healthcare sector has developed certain policies and programs for providing optimal care and support to dementia patients. These policies apply to national, state and regional levels and they aim at preventing the overuse of medications to treat the symptoms of dementia. The World Health Organization has an observatory data that has all the information related to risk education, public awareness, diagnosis, treatment and other facts related to dementia and its care. This observatory data is termed as Global Dementia Observatory (GDO) and it is based upon the policies related to dementia.

Different countries have different policies for dementia care; for example, the Australian Government has the policy named National Dementia Support Program (NDSP). It is a government-funded program that provides support to older people suffering from dementia (Australian Government, Department of Health, 2020). The older people with dementia are at high risk of falls and to prevent falls, the government have launched various fall prevention policies. The World Health Organization has launched the program Global action plan on the public health response to dementia 2017-2025 to address dementia as a public health priority. However, all these already established policies and programs related to dementia aim at providing support and care to the patients. They do not focus on preventing the overuse of dementia medications to control the behaviour of patients. These policies are not highly effective because the rate of dementia is still very high across the world. As per the World Health Organization (2019), the prevalence of dementia will reach 152 million in the year 2050.

Consultation Activities

A new policy must be developed by every country to prevent the overuse of medications for controlling the aggressive behaviour of dementia patients. As per this policy, all the medical professionals would be having the rights to report complains about their colleagues or other healthcare professionals who use an overdose of medications to treat dementia people. All the current policies do not involve any specific guidelines against the overuse of medications or the use of harmful drugs such as psychotropic. There is an urgent need to modify the guidelines of old policies related to dementia; all these policies must include strict rules against the use of unethical and illegal methods to treat dementia people. The common symptoms of dementia include loss of choiceness; cognitive impairment and memory loss.

The dementia patients are unable to express their problems to other people because of poor problem-solving and decision-making skills. This is the reason that some of the healthcare professionals or registered nurses use unethical ways to control such patients. They use unethical ways to improve patient outcomes without providing patient-centred care plan. This can deteriorate the medical conditions of the patient and in severe cases can be fatal also. Thus, both the current policies and the new policies must focus on banning the illegal and unethical ways of treating dementia patients. Another recommendation that can enhance patient care in dementia is mandatory reporting. As per the Australian Government (2020), the aged care laws have a provision named mandatory reporting or compulsory reporting. According to this provision, all the healthcare professionals and people working in the healthcare sector have the right to complain about any illegal or unethical approach used by the other healthcare professionals to treat the older adults.

Moreover, the Government should try to provide more funds to the organizations working for dementia care. It has been observed that the Government mostly provides funds for the implementation of the policies but it does not give sufficient funds for the monitoring and evaluation of policies. This is the reason that most of the policies related to dementia and dementia care are not evaluated properly and their success rate is not accurate. As a result, the Government should provide sufficient funds to all the current and new policies related to dementia. This will help in improving patient care and patient outcomes; and will also help in reducing the prevalence of dementia across the world. The Government should try to promote the new policy of banning the overuse of medications and usage of harmful psychotropic drugs for treating dementia patients. Training sessions should be conducted for older people to provide them with more information about the harmful effects of medications on dementia patients. The registered nurses and other healthcare professionals must be made aware of the mandatory reporting provision of the aged care laws. All these recommendations can help in reducing the deaths of dementia patients due to the medication administration. This will also bring transparency to dementia patients and healthcare professionals. The patients and their families must actively participate in understanding the new policies related to dementia care.

Literature Review of Policy and Practice in the Care of Older People

The Australian policy, National Dementia Support Program (NDSP) is a government-aided program providing support to the older people suffering from dementia. Although it focuses at providing care and support, by empowering them (Australian Government, Department of Health, 2020), it does not focus on preventing the overuse of dementia medications being used to control the behaviour of dementia patients, thus this policy is inadequate as the dementia rate is still high in Australia. Elliott, Goeman, Beanland and Koch (2015) stated that impairment of cognitive abilities in the patients suffering from dementia significantly impact their capability of managing the medications. Their study was based on the review of contemporary published literature between the years 2003 and 2013 to explore the management of medicines by the people having cognitive abilities impaired, such as dementia patient, the methods to access their ability to manage medications safely and the strategies that can provide independent management of medications to them.

They further demonstrated that while numerous strategies have been implemented to promote the independent management of medications among dementia patients, very little follow-up efforts have been taken to check the outcomes of these strategies and that further research is required to develop strategies/approaches to encourage safe management of their medications by older people having impaired cognitive abilities and dementia, and their caretakers (Elliott, Goeman, Beanland & Koch, 2015). This suggests that people with impaired memory and other cognitive abilities are unable to take care of their medications and therefore are unaware of the benefits and harms imparted by the medicines they are given by other people, including their caretakers and healthcare professionals.

Since the patients suffering from dementia are usually aggressive and their unfavourable behaviour triggers the medical practitioners to make use of medicines which can impart harm in the long run including the overuse of dementia medications and the use of psychotropic medications. Vasudev et al. (2015) published a study based on the collected data related to drug-claims of all elderly people (age ≥ 65 years) in Ontario, Canada from January 2004 to March 2013 to evaluate the quarterly rates of prescriptions of 6 classes of psychotropic drugs. In this study, they demonstrated that the majority of dementia patients (75%-79%) were administered with at least one psychotropic medication. They further stated that substantial growth in the prescription of both sedatives (15% rise) and non-sedatives (9% rise).

The proportion of elderly adults suffering from dementia and dispensed with 2 or more number of psychotropic drugs were also reported to increase, i.e. from 42 %in 2004 to 50% in 2013 (Vasudev et al., 2015). Furthermore, Maust et al. (2015) stated that antipsychotic medicines are related to the aggravated rate of mortality in elderly adults, who are patients of dementia and found out that the patients receiving certain antipsychotic medicine were having an increased risk of mortality by 2% to 12.3%, with a varying number needed to harm for different medications. They concluded that the absolute influence of antipsychotic medications on the rate of mortality in elderly adults suffering from dementia can be higher than what is already known and it increases as the intake increases (Maust et al., 2015). Additionally, Shin et al. (2016) concluded in their study that there is the high rate of concurrent consumption of antipsychotic medications along with anti-dementia medications for long use durations and thus the antipsychotic medication use should be attentively monitored to ameliorate the patient outcomes. These studies suggest that there is a need for an effective policy to take care of all the shortcomings of keeping dementia patients from having the best quality of their lives for as long as possible.

Implementation of The Policy

The implementation is one of the important aspects of the policy framing process and accurate implementation is required to improve the issue related to the topic. Four stages are needed to be included in the implementation plan that includes stakeholder, organization procedure, individual skill and technique introduction (Khan, 2016). The stakeholders play a major role in the policy implementation as they are directly involved in funding and planning of the implementation procedure for the policy. There are different groups of the stakeholder that are involved to accurately implement the policy and the first type of stakeholder includes government bodies that will be utilized to fund the policy implementation. The government bodies help to provides funds accurate funds for the policy implementation and help to frame implement the policy (Lemke & Harris-Wai, 2015).

The non-government organization also plays a major role in helping the organization to implement the change in the policy. The non-government organization helps to promote the engagement of the resources concerning the policy implementation process (Peters et al., 2017). The health care staff also has a crucial role as a stakeholder as they are involved in conducting the changes in the policy. The health care professional should assist the change in the policy which helps to improve the policy (Norris et al., 2017). The changes that are required to improve the policy will include two aspects that include improving the guidelines concerning the overdose of medicine and unethical way of treatment concerning the dementia patient. The organization can improve the guidelines by addressing the gap in the policy that helps to decrease the chances of an overdose of medicine. The changed guideline should be informed to the health care professional to improve the care process that will reduce the chances of the health-related complication.

The health professional training should be conducted to improve the understanding of reading the accurate dose and ethical way of treating the dementia patient. The nurses are expected to work according to the ethical framework to improve the care process and reduce the chances of ethical issue that can arise due to the illegal treatment of the patient. The training should include improved guideline and accurate treatment procedure that can be utilized to improve their understanding. Another aspect is the improvement of the Individual skills that are needed to be improved to implement the changes. The change in the policy should also include better patient understanding that can be utilized to improve the care process. The change in the policy can be implemented by utilizing the educational intervention that aims to improve the knowledge of the patient concerning the care process. The educational aspect will include medication doses, accurate care treatment and importance of different care process. The educational process will help to improve the understanding of the patient that directly promotes patient participation in the care which reduces the chances of omission in the care.

The technical process should also be improved to implement the mandatory reporting procedure. There is a need to ameliorate the mandatory reporting system in the organization as it helps to reduce the time required to report the issue in the care system. The organization system should improve the mandatory system by forming a special team to address the different issue that requires urgent attention. This should include training of the technical staff to utilize the skill to improve the procedure for the mandatory reporting and effectively work against the issue raised in the complaint. The implementation of the policy will also include the feedback procedure that helps to evaluate the impact of the change over the individual mental health. The feedback process will include two aspects of patient assessment and patient survey. The psychiatric assessment method is used to analyse the patient condition concerning the changes in the policy as it helps to understand the mental state of the patient (Jethwa, 2015). The next step is surveying with the patient to understand their health status and knowledge concerning the care process.

Conclusion on Policy and Practice in the Care of Older People

Dementia is one of the major causes of dependency and disabilities in elderly adults. Around 50 million people are diagnosed with dementia every year across the world, most of whom are elderly adults. As these patients find carrying out daily activities troublesome, more support and care is required for them. Although, healthcare professionals and other people are found misusing certain medicines to conveniently make the aggressive behavioural symptoms of dementia patients disappear. This calls out for the need for effective policies to take care of these illegal activities done with older dementia patients. Current policies, such as the National Dementia Support Program (NDSP) of Australia, aim at providing support to dementia patients and their carers but no policy is currently available to keep checks on the treatment provided to dementia patients via implementing strict rules against the use of unethical and illegal methods used to treat dementia people. Symptoms of dementia include impaired memory and cognitive abilities along with loss of problem-solving skills therefore, special patient-centred care should be provided to these patients. Furthermore, pre-existing studies demonstrate that excessive use of antipsychotic medications increases the rate of mortality. Thus, the implementation of new policies and the modifications in the existing policies are required. Stakeholders, organisation procedure, individual skills and introduction of techniques are among the various aspects that will have to be taken into consideration while introducing a new policy aimed at amelioration the health outcomes of elderly dementia patients.

References for Policy and Practice in the Care of Older People

Australian Government, Department of Health. (2020). National dementia support program (NDPS). 

Australian Government. (2020). Guide for aged care staff - compulsory reporting. 

Elliott, R. A., Goeman, D., Beanland, C., & Koch, S. (2015). Ability of older people with dementia or cognitive impairment to manage medicine regimens: a narrative review. Current Clinical Pharmacology, 10, 213-221. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5396255/pdf/CCP-10-213.pdf

Human Rights Watch. (2019). Australia: Older people in aged care drugged up. Retrieved from https://www.hrw.org/news/2019/10/15/australia-older-people-aged-care-drugged

Jethwa, K. D. (2015). Psychiatric assessment of patients with dementia in the community. The British journal of general practice: the journal of the Royal College of General Practitioners, 65(637), 416. https://doi.org/10.3399/bjgp15X686173

Khan, A. R. (2016). Policy implementation: some aspects and issues. Journal of Community Positive Practices, 16(3), 3-12. Retrieved from https://www.researchgate.net/publication/320549262_POLICY_IMPLEMENTATION_SOME_ASPECTS_AND_ISSUES

Lemke, A. A., & Harris-Wai, J. N. (2015). Stakeholder engagement in policy development: challenges and opportunities for human genomics. Genetics in medicine: official journal

of the American College of Medical Genetics, 17(12), 949–957. https://doi.org/10.1038/gim.2015.8

Lim, H. R. & Sharmeen, T.(2016). Medicines management issues in dementia and coping strategies used by people living with dementia and family careers: A systematic review. International Journal of Geriatric Psychiatry, 33(12), 1562-1581. DOI 10.1002/gps.4985

Maust, D. T., Kim, H. M., Seyfried, L. S., Chiang, C., Kavanagh, J., Schneider, L. S., & Kales, H. C. (2015). Antipsychotics, other psychotropics, and the risk of death in patients with dementia: number needed to harm. JAMA Psychiatry,72(5),438-445. DOI 10.1001/jamapsychiatry.2014.3018

Norris, J. M., White, D. E., Nowell, L. (2017). How do stakeholders from multiple hierarchical levels of a large provincial health system define engagement? A qualitative study. Implementation Science, 12(98), 1-13. https://doi.org/10.1186/s13012-017-0625-5

Peters, D. H., Bhuiya, A. & Ghaffar, A. (2017). Engaging stakeholders in implementation research: lessons from the Future Health Systems Research Programme experience. Health Res Policy Sys 15(104), 1-73. https://doi.org/10.1186/s12961-017-0269-6

Shin, H. Y., Gadzhanova, S., Roughead, E. E., Ward, M. B., & Pont, L.G. (2016). The use of antipsychotics among people treated with medications for dementia in residential aged care facilities. International Psychogeriatrics, 28(06), 977–982. DOI 10.1017/S1041610215002434

Vasudev, A., Shariff, S. Z., Liu, K., Burhan, A. M., Herrmann, N., Leonard, S., & Mamdani, M. (2015). Trends in psychotropic dispensing among older adults with dementia living in longterm care facilities: 2004-2013. The American Journal of Geriatric Psychiatry, 23(12). DOI 10.1016/ j.jagp.2015.07.001. World Health Organization. (2019). Dementia. Retrieved from https://www.who.int/news-room/fact-sheets/detail/dementia

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